Parents with Psychosis: Impact on Parenting & Parent-Child Relationship

Objective: This systematic review explores the impact of parents with psychosis on parenting and parent-child relationship. Method: Psychiatric disorders in which psychosis may be found such as; schizophrenia, bipolar disorder (manic-depressive) and personality disorders, studies assess either fathers or mothers as parents experiencing psychosis and samples of children or adolescents aged until 18 were included in the review. As the search strategy; PsycINFO, Ovid MEDLINE, Embase, Maternity and Infant Care, PsycARTICLES and Cochrane databases were searched from the beginning of databases. Seven studies were reviewed. Results: Overall, studies portray consistency on the fact that having parents with psychosis induces chaotic, ambivalent communication; severe impairments in the ability of parenting; parenting stress; disorganized, disrupted parenting as well as maladjusted relationship; parents experiencing burden of nurturing and features of permissive, neglectful and authoritarian parenting styles. Conclusion: In families where parental psychotic disorder disrupts parenting and parent-child relationship, the more family functioning and parents are supported, less possible negative outcomes and disorganization occur. There is a significant lack of psychological support for parents with psychotic disorders, so that necessity for treatment and support is indisputable.


Introduction
Psychosis is a mental state that is defined as "A severe mental illness, derangement, or disorder involving a loss of contact with reality, frequently with hallucinations, delusions, or altered thought processes, with or without a known organic origin. '' [1]. A psychotic experience or episode is diagnosed when one or more of the following symptoms is present: delusions, hallucinations, disorganized speech (e.g., frequent derailment or incoherence), grossly disorganized or abnormal motor behaviour (including catatonia) and negative symptoms. Thus, among all, the most common symptoms of psychosis are delusions and hallucinations [1].
"Psychosis is a term used to cover a range of mental illnesses where psychotic symptoms typically occur'' [2]. The primary disorders comprise schizophrenia, schizoaffective disorder, delusional disorders, schizophreniform disorder and brief psychotic disorder. On the other hand, it can be attributable to more general mental health conditions, personality disorders, psychoactive substance or mood disorder for instance major depression or bipolar disorder [2][3][4].
Schizophrenia is the most common psychotic disorder and it occurs at the same rates across women and men. Thus, as it's assumed that women and men are affected by psychosis to the same extent, the same holds true for parents (either mothers or fathers).

Psychosis and Parenting
The link between parents experiencing mental health problems as psychosis and negative impact for parenting and parent-child relationship has been long acknowledged [5]. It's also known that even though parental mental health has numerous impacts on parenting, it's possible to say that parental negativity and harsh or ineffective discipline practices represents two major dimensions in relation to child-parent relationship [5].
Parenting (or child rearing in other terms), as a concept, primarily reveals the act of raising not only the children but also the responsibilities and activities involved. In general, it comprises promoting physical, emotional, social, financial and intellectual development of a child. Additionally, there are multiple determinants of parenting including developmental history, personality traits of parents, work, parental sense of competence/self-efficacy and selfregulation, couple relations, social network, characteristics of children; other than co-existing mental health status, which is the foremost emphasis of the paper. Besides, in order to examine the impact of parental mental disorder on parent-child relationship and parenting, it's necessary to recognize basic needs of children that must be contributed through 'good-enough' parenting. It's possible to explore these needs in three different categories; physical needs such as nutrition, warmth, contact/comfort, safety; social needs such as interaction, learning, socialization, limit-setting; and emotional needs such as empathy, availability, consistency, building of self-esteem or attachment which may discompose both parenting and familial relationships when there is a parental mental disorder [6].
The adverse effects of parents experiencing major psychiatric disorders, i.e. psychotic episodes or psychosis on parenting and parentchild relationship is indubitable [7]. "The primary symptoms intrude directly into the individuals parenting role through, for example, increased irritability or aggressiveness, unresponsiveness, critical attitudes, unrealistic expectations and difficulty planning ahead of everyday needs". Moreover, it's possible to claim that, relevant to parents experiencing psychosis, parental behaviour such as distorted expressions of reality or strange behaviour/beliefs portray the root for children experiencing anxious, confused, perplexed relationship with family functioning has been an area of considerable interest to researchers. Apart from the familial properties of schizophrenia and affective psychoses, having a family member with a mental illness, places considerable stress on the family system" [9].
"Psychotic ideation, with distorted expressions of reality and strange beliefs, is usually frightening and confusing to children, or else they can feel ashamed of their family'' [7]. Looking at the previous studies and researches done on the impact of parental psychotic disorders on parenting and family functioning, it's possible to claim that there is relatively insufficient amount of evidence. On the other hand, there is a significant literature findings explored angle of parent-child relationships (especially the mother as the parent) where the mother experiences schizophrenia. Nonetheless, it's less reported in literature that psychosis has consequences on a generous scope of issues related to family functioning and parenting [8].
This article aims at examining the impacts of parents experiencing psychosis on parenting and parent-child relationship. It questions the possible ways psychotic disorders precipitate negative outcomes on both parenting and interaction between parents and children. Thus, children from 0 to 18 years of age (in other words, from infancy to late adolescence) and both mothers and fathers will be covered within the objective.

Search strategy
A systematic search of PsycINFO, Ovid MEDLINE, Embase, Maternity and Infant Care, PsycARTICLES and Cochrane databases was conducted for articles up to 2015 using key search terms including combinations of the following categories: (i) parents, mother, father, parent-child interaction, family, child care, nurture, early environment, impact; and (ii) psychosis, schizophrenia, schizoaffective disorder, delusional disorders, schizophreniform disorder and brief psychotic disorder. The articles were searched from the beginning of the databases. 1,370 articles were identified through the database search; 350 articles were identified as duplicates; 1,020 records were screened and among those 230 full-text articles were assessed for eligibility. With excluding 213 full-text articles with reasons, in total 17 articles (both qualitative and quantitative synthesis) included for full-text screening. Furthermore, 4 additional book resources were included for the review.

Inclusion criteria
Studies that assess parents with psychosis and it's impact on parenting and parent-child relationship. Psychiatric disorders in which psychosis may be found are schizophrenia, bipolar disorder (manicdepressive) and personality disorders. Studies assess either fathers or mothers as parents experiencing psychosis. Children or adolescents aged until 18. Methodological qualities are assessed; both qualitative and quantitative were included.

Exclusion criteria
Studies published in non-English journals. Commentaries, editorials, dissertation and conference abstracts or case studies. Studies include parental mental illnesses other than psychotic disorders and interventions for mentally ill parents. Studies explore impact of parental mental illness on children's wellbeing & development.

Results
The quantitative study examining experiences of Australian parents with psychosis, recruits 1825 people living with symptoms of, or a diagnosis of, psychosis through a national survey conducted with faceto-face interviews consisting clinical, demographic and parenting focused information. The research outlines that although majority of the parents living with psychosis function well in terms of the quality of care they provide to their children and their participation in childcare at the level of an average carer of same sex/age, a compelling distribution has deterioration in parenting and overall functioning that may lead to detrimental outcomes on parent-child interaction: "… around a quarter of parents were rated as having obvious or severe impairments in the ability to care for their child or children'' [10].
A quantitative research conducted in 2005, undertakes parenting as a mediator where mothers have mental disorders including schizophrenia, major affective disorder or bipolar disorder. The research obtained data of maternal psychiatric functioning, diagnosis and parenting through three particular estimates as demographics/ diagnosis, maternal functioning and parenting from 317 racially diverse mothers with mental illnesses. Structural equation modelling was used in the analysis. Essentially, one of the study hypotheses is validated through the evidence that; symptoms of maternal mental illnesses are correlated with disrupted and permissive parenting, reduced parenting determination and also basics of authoritarian parenting style.
The study conducted in St. Louis draws it's research sample of 43 parents from various psyhiatric, general and special hospitals. It evaluates the home environment in which parents experience psychosis and portrays that especially when the mentally ill parent is the mother, children experience unaided and inconsistent lives seperate from their parents, through interviews. In other words, the parent experiencing psychosis is usually unable to provide supervision and discipline to the child. 9 Likewise, one possible disrupted family environment is expressed through these words; "The reactive environment is characterized by it's inconsistency, chaotic management, contradictory communications, highly ambivalent but powerful affects, incoherent intentions and motives, and it's disturbing degree of intrusiveness into the lives of the children'' [9].
As a distinctive point of view, the findings of the pilot study in 2002 by Plant et. al. that used self-report measures to examine the effect of parents with psychosis on family functioning. In the study, the subjects were initiated through newsletters, Community Mental Health clinics and contact with the individuals who were participated in a previous research at Queensland Centre for Schizophrenia Research. The participants were assessed through Schedule for the Assessment of Clinical Neuropsychiatry (SCAN). The personal reports in regard to family functioning indicate that: "Most parents reported that they were effective parents (90%), however 30% reported low levels of satisfaction in their parenting role. Almost half of the participants (45%) reported high levels of parenting stress. In their parenting style, participants reported that they were often lax and had difficulty in following through with consequences if their children misbehaved. '' Apart from these findings, the study examines the correlation between symptoms (both positive and negative) of psychotic disorder and selfreports of family functioning. Based on the measures results gained from Family Assessment Measure, Parenting Stress Index, Parenting Sense of Competency Scale, Ways of Coping Questionnaire, Coping Resources Inventory, Perceived Social Support Inventory and Parenting Scale; negative symptoms (i.e. being withdrawn, loss of ability in emotional response to people or events) were linked with maladjusted parent-child relationship where there is parental distress. On the other hand, positive symptoms (i.e. hallucinations) were associated with disorganized and disrupted parenting styles where there is unsupportive, rejecting, uninvolved and neglecting interaction. Lastly, the self-report results portray that: "Nearly a half of the participants in this study reported high levels of parenting stress, and a third reported low levels of satisfaction in their role. Fourteen percent rated their own parenting skills as 'poor'' [8].
Moreover, another study conducted in 2008, portrays a qualitative investigation of 10 white fathers having diagnosis of psychotic disorder (schizophrenia, schizoaffective or other psychotic-type disorder) where data was analysed by Interpretative Phenomenological Analysis. The research findings state that experiencing psychosis lead to a sense of emotional withdrawal for the parent which relatedly impairs parentchild relationship. In addition, it's claimed that psychotic disorder basically interferes the fathers from fulfilling their parental role: "Research has found that parents with mental illness are more likely to demonstrate parenting deficits, and this is associated with mental illness in their children'' [11]. Additionally, based on the interviews conducted with fathers, it's claimed that psychosis impairs the fatherchild interaction in a way that the fathers feel detached, alienated and disengaged in the relationship; likely attributed to delusions and/or hallucinations as possible symptoms of psyhotic disorders. "For example, one father said: " ...something inconceivable took over my body and I can't sort of like be a father to him…I don't feel fatherly to him at all…I feel isolated from him'' [11].
A qualitative research studying the views and experiences of severely mentally ill mothers was conducted in 2004 in London through semi-structured interviews with 22 mothers having schizophrenia, bipolar affective disorder or severe depression with psychotic symptoms. In the study where participants' experiences were discussed, thematic content analysis were implemented. The research illustrates far-reaching data on difficulties associated with motherhood. "It's very difficult when you're wrapped up in your own emotional needs to look at the emotional needs that your children have.'' as one of the interviewed mothers reported [12]. Similarly, some mothers expressed their experience of burden of nurturing their children while trying to guide their own mental-wellbeing. Further, it's revealed that the medication used for psychotic disorder notably disrupts the parenting skills and ability to fulfill physical, emotional or social needs of their children; basically because that the medicines diminish their ability to concentrate on any particular task. Based on the reports, this becomes valid in the recurrence of symptoms or particularly in the severe circumstances of the disorder: "When I am really ill, I wish the children were not there so I wouldn't have that burden to bear. I can't cope with them; their demands are too much for me. And I keep on struggling until eventually I just break down.'' [12].
On the contrary, another article written by Newman et. al. focusing on mentally disturbed parents including mothers and fathers with psychotic disorders, indicates that; even though the child forms an intense relationship and attachment with the mentally ill mother at young ages, later in life when the child begins to experience autonomy, their interaction becomes challenging especially for the mother in a way that she does not only starts feeling stress and frustration but also as concerns this stage as a rejection and torture for herself [13,14]. In connection, the intense mother-child relationship becomes disrupted. Besides, the article briefly discusses possible negative outcomes for the family environment when it's the father having psychosis. "When the father is the psychotic parent, the force of his pathology sets the stage for the family drama. His needs, fears, conflicts, and fantasies dominate the life of the family and create the environment and it's mythology to which wife and ultimately his children must adapt" [14].
Additionally, the study depicts that the father's disrupted mental state can have impact on mother-child relationship in a way that the mother may put herself in a role that acts as a buffer between father and child, which possibly leads to negative circumstances such as over protection and over involvement.

Discussion
Overall, studies put forward the association between parental psychotic disorders and negative outcome on parenting and parentchild relationship. They portray consistency on this fact in a way that it induces chaotic, ambivalent communication; severe impairments in the ability of parenting; parenting stress; disorganized, disrupted parenting as well as maladjusted relationship; parents experiencing burden of nurturing and features of permissive, neglectful and authoritarian parenting styles. Thus, the findings are consistent with other previous reviews in terms of negative outcomes [15][16][17][18]. Additionally, the studies illustrate differences in terms of methodologies (i.e. quantitative and qualitative) and in questions they aim to answer.
Furthermore, there are various limitations of the literature reviewed. Firstly, there are small number of researches undertaking parents with psychosis and it's impact on parenting, with having significantly more qualitative studies in terms of methodological quality; which may limit it's generalizability in a way that findings being limited to the study population. Secondly, the researches found focus more on maternal psychotic disorders and mother-child relationship; so that there is less evidence of fathers having psychosis and father-child interactions. As a third point, there was lack of explanation of the mechanisms focusing specifically on how and in which ways does the psychosis impact parent-child relationship. Therefore, more work needs to be done in exploring father's psychosis and its impact. Hence, more research will need to be done for quantitative studies to examine the findings emerging from qualitative studies, for a more comprehensive explanation of negative outcomes [19].
On the other hand, there are certain limitations of this review. Certainty or satisfaction of the results are questionable by means of no criteria set in choosing qualitative and quantitative data in order to have a sufficient number of literature to review. Additionally, concentrating on the mental state of "psychosis'' leads the inclusion criteria being broad so that the study populations are varied and confounding variables could have possible impacts on the association between parental psychotic disorders and parenting or parent-child interaction.
Lastly, some previous researches focus on the need for support in order to enable parents with mental illnesses to parent in most effective ways. In families where parental psychotic disorder that disrupts parenting and parent-child relationship, the more family functioning and parents are supported thus less possible negative outcomes and disorganization occur [5,20]. "Women diagnosed with illnesses including schizophrenia, schizoaffective disorder, bipolar disorder, and major affective disorders often parent without adequate support from psychiatric and behavioural health providers'' [21][22]. This indicates that there is a lack of psychologically focused support for parents with psychotic disorders which can lead to persistent parent-child conflicts and poor parenting; so a need for treatment and support is crucial.